Week 7 - Contraception & Sexual Health Flashcards
General Features of Combined Hormonal Contraceptives (CHCs)
Forms
Primary Action
Secondary Actions
Correct Use
Diarrhoea/Vomiting
1.) Forms - oral (COCP), (Evra) patch, vaginal ring
2.) Primary Action - inhibits the HPG axis
- inhibiting the HPG axis –> ↓LH and ↓FSH
- no LH surge or follicle stimulation –> no ovulation
3.) Secondary Actions
- progesterone (low dose) thickens cervical mucus
- progesterone inhibits oestrogen, ↓endometrial hyperplasia, inhibiting implantation
4.) Correct Use - must ensure not pregnant
- start on the first day of the menstrual cycle, if not, use barrier protection for the first 7 days
- 21 days on, 7 days off (mimic menstruation)
- if only one pill is missed, can continue as normal
5.) Missed Pill Rules - if only one pill is missed, can continue as normal, if 2+ pills missed then the rules are:
- 1st Week: take another pill ASAP, take emergency contraception, and condoms for the next 7 days
- 2nd Week: take another pill ASAP
- 3rd Week: take another pill ASAP, finish the pack, skip pill-free intervals and start the next pack instantly
5.) Diarrhoea/Vomiting - for the COCP
- <3hrs: take another pill ASAP
- persists >24hrs: use contraception for 7 days afterwards, if last 7 pills, start next cycle immediately
- CYP inducers can reduce the efficacy of the COCP: rifampicin, topiramate, phenytoin, carbamazepine, barbiturates, St Johns Wort, some antiretroviral
Usage of CHCs
Indications
UK MEC4 Contraindications
UK MEC3 Contraindications
Important Side Effects
1.) Indications - contraceptive but also for:
- acne, PMS, menorrhagia, dysmenorrhoea
- endometriosis, PCOS, menopause
- ↓risk of endometrial, cervical, colorectal cancer
2.) UK MEC4 Contraindications - unacceptable risk
- personal history of DVT, PE, stroke or IHD
- >35 years old smoking >15 cigarettes per day
- migraine with aura (due to ↑ischaemic stroke risk)
- uncontrolled hypertension
- recent major surgery with prolonged immobilisation
- postpartum: <3 weeks OR <6 weeks if breastfeeding
- breast cancer
- SLE with positive antiphospholipid antibodies
3.) UKMEC3 Contraindications - disadvantages > adv
- FH of DVT/PE in first-degree relative < 45 years old
- >35 years old smoking of < 15 cigarettes per day
- migraine with no aura, BMI > 35,
- controlled hypertension, immobility (e.g. wheelchair)
- breastfeeding and 6 weeks to 6 months postpartum
4.) Important Side Effects
- headache, nausea, abdominal pain, depression
- menstrual irregularities, breast pain
- breakthrough bleeding: use for 3 months, if it doesn’t settle, change contraception
Progesterone Only Pill (POP)
Mechanism of Action (MOA)
Indications
Contraindications
Correct Use
Important Side-Effects
1.) MOA - low dose progesterone
- thicken cervical mucus but doesn’t inhibit LH surge
2.) Indications - often when CHCs are contraindicated
- can reduce the risk of endometrial cancer
- can be used to manage dysmenorrhoea
3.) Contraindications
- current/past breast cancer
- decompensated cirrhosis, liver cancers
4.) Correct Use
- start on days 1-5 of the menstrual cycle
- POP becomes effective within 2 days if started mid-cycle, before which time barrier methods of contraception are needed
- daily at the same time (within 3 hours) w/ no break
- missed pill: 3 hour window (>27hrs since last pill), take the pill and use barrier contraception for 48 hours
- vomiting and diarrhoea counts as a missed pill
5 .) Important Side Effects
- breast tenderness, menstrual irregularities (esp bleeding), but these are often transient on initiation
- ↑risk of breast cancer, ovarian cysts, ectopic preg..
- DDIs: antibiotics, antiepileptics, St John’s wort
Implant and Injections
Mechanism of Action (MOA)
Implant
Injections
Contraindications
Important Side-Effects
1.) MOA - high dose progesterone
- inhibits LH surge to prevent ovulation
- thickens cervical mucus, ↓endometrial proliferation
2.) Implant - a small tube inserted under the skin
- lasts for 3 years and fertility returns instantly
- Nexplanon implant is the most common
3.) Injections - IM injections every 12 (8-13) wks
- can’t be removed so side effects continue for a while
- can take up to 1 year for fertility to return
- not recommended for >50s due to osteoporosis risk (due to reducing mineral bone density)
4.) Contraindications
- current/past breast cancer
- decompensated cirrhosis, liver cancers
5.) Important Side Effects
- irregular bleeding patterns, breast tenderness
- ↑risk of breast cancer
- implant only: DDIs (liver inducers), acne
- injections only: weight gain, ↓bone density
Intrauterine Contraceptives (IUD and IUS)
Mechanism of Action (MOA)
Advantages
Disadvantages
Important Side Effects
1.) MOA - IUD has copper, IUS releases progesterone
- LNG-IUS releases levonorgestrel (progesterone), preventing implantation and thickening cervical mucus
- Cu-IUD has copper which is toxic to sperm and ovum
2.) Advantages
- long-lasting: IUS (3-5yrs), IUD (5-10 yrs)
- fertility returns instantly
- IUS improves periods, can stop completely after 1 yr
- IUD has no hormonal side effects or DDIs
- IUD works immediately (emergency contraception)
3.) Disadvantages
- pain on insertion, expulsion
- IUS takes 7 days to start working
- IUD can make periods longer, heavier, more painful
4.) Important Side Effects
- unscheduled bleeding, uterine wall perforation
- ectopic pregnancy, PID
- IUS only: PMS (headaches, breast pain, bloating, mood swings, depression/anxiety), acne, ovarian cysts
Emergency Contraception (3 Types)
Levonorgestrel
Ulipristal Acetate
Cu-IUD
1.) Levonorgestrel (Levonelle) - inhibits ovulation for 5-7d
- one 1.5mg tablet taken within 3 days of UPSI (within 5 days if other methods are contraindicated)
- 2 tablets (3mg) if BMI >26 (or >70kg) OR taking any enzyme-inducing drugs e.g. rifampicin
- need a second dose if vomit within 3 hours
- preferred method if you can’t exclude pregnancy
- hormonal contraception can be started immediately but barrier contraception is recommended for 7 days
- side-effects: N+V, dizziness, diarrhoea, breast tenderness, menstrual irregularities
2.) Ulipristal Acetate (EllaOne) - selective progesterone receptor modulator (SPRM) which inhibits or delays ovulation
- one 30mg tablet taken within 5 days of UPSI (need a second dose if vomit within 3 hours)
- avoid if also taking drugs ↑gastric pH (PPIs, H2 antagonist)
- hormonal contraception should only be restarted after 5 days w/ barrier contraception for 7 days
- contraindicated in patients with severe asthma
- breastfeeding should be delayed for 1 week
- side effects: N+V, dizziness, abdo/back/pelvic pain, fatigue, tender breasts, painful periods, mood changes
3.) Cu-IUD - inserted within 5 days of UPSI OR within 5 days of the estimated ovulation date
- most effective form of emergency contraception because it is not affected by BMI unlike ^^^
- often used if they also want ongoing protection
- prevents fertilisation due to toxic copper effects
- preferred method if ovulation has occurred (can also be given up to 5 days after ovulation)
- also preferred if on liver enzyme-inducing drugs
Sterilisation
Vasectomy
Tubal Occlusion
1.) Vasectomy - vas deferens is cut or tied so no sperm
- lower failure rate (1/2000)
- requires semen analysis after 16-20wks (4-5 months) to show azoospermia (success), additional contraception must be used until azoospermia is confirmed
- NHS does not offer routine reversal
2.) Tubal Occlusion - fallopian tubes cut or blocked
- must wait at least 4 weeks after the procedure
- higher failure rate (1/200)
- increased risk of ectopic pregnancy
- NHS does not offer routine reversal
Fraser Guideline and Gillick Competence
Fraser Guidelines - children (u16) must be assessed for competence before contraception advice/treatment
- doesn’t apply if the patient is 13 and under
1.) person understands the practitioner’s advice
2.) cannot be persuaded to inform their parents
3.) will have intercourse with or without contraception
4.) refusing help affects their physical/mental health
5.) in patient’s best interest to avoid parental consent
Gillick Competence - assess child’s (u16) competence
- used in wider context not just contraception
1.) age, maturity, mental capacity
2.) understand adv, disadv, potential long-term impact
3.) understand risks, implications and consequences
4.) understand any advice/ information given
5.) understand any alternative options, if available
6.) can explain rationale behind decision making
